Obama Administration to Investigate Insurers for Bias Against Costly Conditions

WASHINGTON — The Obama administration said Monday that it would investigate prescription drug coverage and other benefits offered by health insurance companies to see if they discriminated against people with AIDS, mental illness, diabetes or other costly chronic conditions.

The administration said it had become aware of “discriminatory benefit designs” that discouraged people from enrolling because of age or medical condition.

In a letter to insurers, administration officials said that a health plan could be engaging in unlawful discrimination if its list of approved drugs excluded all medicines needed to treat a particular condition, or if it restricted access to such drugs by charging large co-payments or requiring prior authorization.

The Centers for Medicare and Medicaid Services said it would focus on companies in the federal insurance marketplace. For each health plan, it said, it will try to determine the “estimated out-of-pocket costs associated with standard treatment protocols for specific medical conditions using nationally recognized clinical guidelines.” The conditions, it said, are likely to include bipolar disorder, diabetes, H.I.V., rheumatoid arthritis and schizophrenia.

The Affordable Care Act says that insurers must accept all applicants for coverage and cannot charge higher premiums because of a person’s pre-existing conditions or disabilities. Advocates for people with H.I.V./AIDS and certain other illnesses have complained that insurers were unduly limiting access to benefits.

Kevin M. McCarty, the Florida insurance commissioner, last week reached an agreement with Humana that significantly reduces the amounts that patients must pay for drugs to treat H.I.V. Patients had been paying 50 percent for some of the more expensive H.I.V. medications. Their share will now be 10 percent.

Thomas T. Noland Jr., a senior vice president of Humana, said, “Florida has a unique law providing insurance-related protections to individuals with H.I.V./AIDS.” Humana denied that it had violated the law, but Mr. Noland said, “We understand the affordability challenges facing those with H.I.V./AIDS because of the relatively high cost of their specialty medications.”

In recent weeks, Mr. McCarty has reached similar, more limited agreements with two other insurers, Cigna and Coventry Health Care, a unit of Aetna.

Insurers, also known as insurance issuers, typically classify drugs into three or more categories with different levels of co-payments and cost-sharing.

In its letter to insurers, the administration said, “If an issuer places most or all drugs that treat a specific condition on the highest-cost tiers, that plan design effectively discriminates against, or discourages enrollment by, individuals who have those chronic conditions.”

Likewise, the administration said, “age limits are discriminatory when applied to services that have been found clinically effective at all ages.” The administration said it would challenge restrictions on benefits if they were “not based on clinically indicated, reasonable medical management practices.”

Andrew Sperling, a lobbyist at the National Alliance on Mental Illness, an advocacy group, said he welcomed the new standards.

“When a doctor follows recommended treatment guidelines,” Mr. Sperling said, “the cost-sharing should not be so burdensome that it discourages patients from adhering to the treatment.” In some health plans, he said, patients are routinely required to pay 40 percent to 50 percent of the costs for drugs to treat bipolar disorder and schizophrenia.

The administration also issued new rules requiring insurers to improve the accuracy of publications listing their doctors and hospitals. Consumers have found that these directories are full of errors and often include doctors who are not affiliated with the insurers’ health plans.

But after vigorous internal debate, the administration decided not to propose new rules that would require insurers to include more doctors and hospitals.

Insurance executives had lobbied against stricter standards. They said that “narrow networks,” with limited numbers of providers, allowed insurers to hold down costs.

The National Association of Insurance Commissioners, representing state officials, is drafting a model law to guide states in regulating networks. Administration officials said they would evaluate that effort before adopting new federal standards.

A version of this article appears in print on , on Page A19 of the New York edition with the headline: Officials to Examine Drug Plans for Bias. Order Reprints | Today’s Paper | Subscribe